Influence on prognosis and morbidity of left ventricular ejection fraction with and without signs of left ventricular failure after acute myocardial infarction

Automated Assessment of Cardiac Systolic Function From Coronary Angiograms With Video-Based Artificial Intelligence Algorithms

Importance

Understanding left ventricular ejection fraction (LVEF) during coronary angiography can assist in disease management.

Objective

To develop an automated approach to predict LVEF from left coronary angiograms.

Design, Setting, and Participants

This was a cross-sectional study with external validation using patient data from December 12, 2012, to December 31, 2019, from the University of California, San Francisco (UCSF). Data were randomly split into training, development, and test data sets. External validation data were obtained from the University of Ottawa Heart Institute. Included in the analysis were all patients 18 years or older who received a coronary angiogram and transthoracic echocardiogram (TTE) within 3 months before or 1 month after the angiogram.

Exposure

A video-based deep neural network (DNN) called CathEF was used to discriminate (binary) reduced LVEF (≤40%) and to predict (continuous) LVEF percentage from standard angiogram videos of the left coronary artery. Guided class-discriminative gradient class activation mapping (GradCAM) was applied to visualize pixels in angiograms that contributed most to DNN LVEF prediction.

Results

A total of 4042 adult angiograms with corresponding TTE LVEF from 3679 UCSF patients were included in the analysis. Mean (SD) patient age was 64.3 (13.3) years, and 2212 patients were male (65%). In the UCSF test data set (n = 813), the video-based DNN discriminated (binary) reduced LVEF (≤40%) with an area under the receiver operating characteristic curve (AUROC) of 0.911 (95% CI, 0.887-0.934); diagnostic odds ratio for reduced LVEF was 22.7 (95% CI, 14.0-37.0). DNN-predicted continuous LVEF had a mean absolute error (MAE) of 8.5% (95% CI, 8.1%-9.0%) compared with TTE LVEF. Although DNN-predicted continuous LVEF differed 5% or less compared with TTE LVEF in 38.0% (309 of 813) of test data set studies, differences greater than 15% were observed in 15.2% (124 of 813). In external validation (n = 776), video-based DNN discriminated (binary) reduced LVEF (≤40%) with an AUROC of 0.906 (95% CI, 0.881-0.931), and DNN-predicted continuous LVEF had an MAE of 7.0% (95% CI, 6.6%-7.4%). Video-based DNN tended to overestimate low LVEFs and underestimate high LVEFs. Video-based DNN performance was consistent across sex, body mass index, low estimated glomerular filtration rate (≤45), presence of acute coronary syndromes, obstructive coronary artery disease, and left ventricular hypertrophy.

Conclusion and relevance

This cross-sectional study represents an early demonstration of estimating LVEF from standard angiogram videos of the left coronary artery using video-based DNNs. Further research can improve accuracy and reduce the variability of DNNs to maximize their clinical utility.

Feasibility of Coronary CT Angiography-derived Left Ventricular Long-Axis Shortening as an Early Marker of Ventricular Dysfunction in Transcatheter Aortic Valve Replacement

Purpose

To evaluate the value of using left ventricular (LV) long-axis shortening (LAS) derived from coronary CT angiography (CCTA) to predict mortality in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

Materials and Methods

Patients with severe AS who underwent CCTA for preprocedural TAVR planning between September 2014 and December 2019 were included in this retrospective study. CCTA covered the whole cardiac cycle in 10% increments. Image series reconstructed at end systole and end diastole were used to measure LV-LAS. All-cause mortality within 24 months of follow-up after TAVR was recorded. Cox regression analysis was performed, and hazard ratios (HRs) are presented with 95% CIs. The C index was used to evaluate model performance, and the likelihood ratio χ² test was performed to compare nested models.

Results

The study included 175 patients (median age, 79 years [IQR, 73-85 years]; 92 men). The mortality rate was 22% (38 of 175). When adjusting for predictive clinical confounders, it was found that LV-LAS could be used independently to predict mortality (adjusted HR, 2.83 [95% CI: 1.13, 7.07]; P = .03). In another model using the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), LV-LAS remained significant (adjusted HR, 3.38 [95 CI: 1.48, 7.72]; P = .004), and its use improved the predictive value of the STS-PROM, increasing the STS-PROM C index from 0.64 to 0.71 (χ² = 29.9 vs 19.7, P = .001). In a subanalysis of patients with a normal LV ejection fraction (LVEF), the significance of LV-LAS persisted (adjusted HR, 3.98 [95 CI: 1.56, 10.17]; P = .004).

Conclusion

LV-LAS can be used independently to predict mortality in patients undergoing TAVR, including those with a normal LVEF.Keywords: CT Angiography, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Outcomes Analysis, Cardiomyopathies, Left Ventricle, Aortic Valve Supplemental material is available for this article. © RSNA, 2022See also the commentary by Everett and Leipsic in this issue.

Extracellular Vesicles Are Associated With Outcome in Veno-Arterial Extracorporeal Membrane Oxygenation and Myocardial Infarction

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is being increasingly applied in patients with circulatory failure, but mortality remains high. An inflammatory response syndrome initiated by activation of blood components in the extracorporeal circuit may be an important contributing factor. Patients with ST-elevation myocardial infarction (STEMI) may also experience a systemic inflammatory response syndrome and are at risk of developing cardiogenic shock and cardiac arrest, both indications for VA-ECMO. Extracellular vesicles (EV) are released by activated cells as mediators of intercellular communication and may serve as prognostic biomarkers. Cardiomyocyte EV, released upon myocardial ischemia, hold strong potential for this purpose. The aim of this study was to assess the EV-profile in VA-ECMO and STEMI patients and the association with outcome.

Methods: In this prospective observational study, blood was sampled on day 1 after VA-ECMO initiation or myocardial reperfusion (STEMI patients). EV were isolated by differential centrifugation. Leukocyte, platelet, endothelial, erythrocyte and cardiomyocyte (caveolin-3⁺) Annexin V⁺ EV were identified by flow cytometry. EV were assessed in survivors vs. non-survivors of VA-ECMO and in STEMI patients with normal-lightly vs. moderately-severely reduced left ventricular function. Logistic regression was conducted to determine the predictive accuracy of EV. Pearson correlation analysis of EV with clinical parameters was performed.

Results: Eighteen VA-ECMO and 19 STEMI patients were recruited. Total Annexin V⁺, cardiomyocyte and erythrocyte EV concentrations were lower (p ≤ 0.005) while the percentage of platelet EV was increased in VA-ECMO compared to STEMI patients (p = 0.002). Total Annexin V⁺ EV were increased in non-survivors of VA-ECMO (p = 0.01), and higher levels were predictive of mortality (AUC = 0.79, p = 0.05). Cardiomyocyte EV were increased in STEMI patients with moderately-severely reduced left ventricular function (p = 0.03), correlated with CK-MB_max (r = 0.57, p = 0.02) and time from reperfusion to blood sampling (r = 0.58, p = 0.01). Leukocyte EV correlated with the number of coronary stents placed (r = 0.60, p = 0.02).

Conclusions: Elevated total Annexin V⁺ EV on day 1 of VA-ECMO are predictive of mortality. Increased cardiomyocyte EV on day 1 after STEMI correlate with infarct size and are associated with poor outcome. These EV may aid in the early identification of patients at risk of poor outcome, helping to guide clinical management.

Assessment of Selected Baseline and Post-PCI Electrocardiographic Parameters as Predictors of Left Ventricular Systolic Dysfunction after a First ST-Segment Elevation Myocardial Infarction

OBJECTIVE

To assess the performance of ten electrocardiographic (ECG) parameters regarding the prediction of left ventricular systolic dysfunction (LVSD) after a first ST-segment-elevation myocardial infarction (STEMI).

METHODS

We analyzed 249 patients (74.7% males) treated with primary percutaneous coronary intervention (PCI) included into a single-center cohort study. We sought associations between baseline and post-PCI ECG parameters and the presence of LVSD (defined as left ventricular ejection fraction [LVEF] ≤ 40% on echocardiography) 6 months after STEMI.

RESULTS

Patients presenting with LVSD (n = 52) had significantly higher values of heart rate, number of leads with ST-segment elevation and pathological Q-waves, as well as total and maximal ST-segment elevation at baseline and directly after PCI compared with patients without LVSD. They also showed a significantly higher prevalence of anterior STEMI and considerably wider QRS complex after PCI, while QRS duration measurement at baseline showed no significant difference. Additionally, patients presenting with LVSD after 6 months showed markedly more severe ischemia on admission, as assessed with the Sclarovsky-Birnbaum ischemia score, smaller reciprocal ST-segment depression at baseline and less profound ST-segment resolution post PCI. In multivariate regression analysis adjusted for demographic, clinical, biochemical and angiographic variables, anterior location of STEMI (OR 17.78; 95% CI 6.45-48.96; p < 0.001), post-PCI QRS duration (OR 1.56; 95% CI 1.22-2.00; p < 0.001) expressed per increments of 10 ms and impaired post-PCI flow in the infarct-related artery (IRA; TIMI 3 vs. <3; OR 0.14; 95% CI 0.04-0.46; p = 0.001) were identified as independent predictors of LVSD (Nagelkerke's pseudo R2 for the logistic regression model = 0.462). Similarly, in multiple regression analysis, anterior location of STEMI, wider post-PCI QRS, higher baseline number of pathological Q-waves and a higher baseline Sclarovsky-Birnbaum ischemia score, together with impaired post-PCI flow in the IRA, higher values of body mass index and glucose concentration on admission were independently associated with lower values of LVEF at 6 months (corrected R2 = 0.448; p < 0.00001).

CONCLUSIONS

According to our study, baseline and post-PCI ECG parameters are of modest value for the prediction of LVSD occurrence 6 months after a first STEMI.

Enhanced Inflammation is a Marker for Risk of Post-Infarct Ventricular Dysfunction and Heart Failure

Acute ST-segment elevation myocardial infarction (STEMI) activates inflammation that can contribute to left ventricular systolic dysfunction (LVSD) and heart failure (HF). The objective of this study was to examine whether high-sensitivity C-reactive protein (CRP) concentration is predictive of long-term post-infarct LVSD and HF. In 204 patients with a first STEMI, CRP was measured at hospital admission, 24 h (CRP₂₄), discharge (CRP_DC), and 1 month after discharge (CRP_1M). LVSD at 6 months after discharge (LVSD_6M) and hospitalization for HF in long-term multi-year follow-up were prospectively evaluated. LVSD_6M occurred in 17.6% of patients. HF hospitalization within a median follow-up of 5.6 years occurred in 45.7% of patients with LVSD_6M vs. 4.9% without LVSD_6M (p < 0.0001). Compared to patients without LVSD_6M, the patients with LVSD_6M had higher CRP₂₄ and CRP_DC and persistent CRP_1M ≥ 2 mg/L. CRP levels were also higher in patients in whom LVSD persisted at 6 months (51% of all patients who had LVSD at discharge upon index STEMI) vs. patients in whom LVSD resolved. In multivariable analysis, CRP₂₄ ≥ 19.67 mg/L improved the prediction of LVSD_6M with an increased odds ratio of 1.47 (p < 0.01). Patients with LVSD_6M who developed HF had the highest CRP during index STEMI. Elevated CRP concentration during STEMI can serve as a synergistic marker for risk of long-term LVSD and HF.

Platelet Membrane Γ-Glutamyl Transferase-Specific Activity and the Clinical Course of Acute Coronary Syndrome

γ-Glutamyl transferase (GGT) participates in oxidative and inflammatory reactions inside the atheroma plaque and platelets. We evaluated whether platelet membrane γ-glutamyl transferase (Plt-GGT) activity is a predictor of major adverse cardiac events (MACEs) during 3 months follow-up of patients with acute coronary syndrome (ACS; MACE-3M). We included 105 patients who were hospitalized consecutively with the diagnosis of ACS. Patients with an MACE-3M were older, more likely to have hypertension, hyperlipidemia, family history of coronary artery disease(CAD), thrombolysis in myocardial infarction (TIMI) risk score >4, higher Plt-GGT and serum GGT activities, serum C-reactive protein level, and lower left ventricular ejection fraction (LVEF) when compared to those without MACE-3M (all P values ≤.05). By receiver–operator characteristic (ROC) curve analysis, 265 mU/mg for Plt-GGT, 30 U/L for serum GGT, and 45% for LVEF were determined as cutoff values to discriminate MACEs. Platelet GGT activity >265 mU/mg, TIMI risk score >4, and family history of CAD were independent predictors of MACE-3M (all P values <.05). Platelet GGT activity was as an independent predictor for MACEs in patients with ACS during the 3 months follow-up.

Determinants and Prognostic Impact of Heart Failure and Left Ventricular Ejection Fraction in Acute Coronary Syndrome Settings

INTRODUCTION AND OBJECTIVES

Contemporary data on the incidence and prognosis of heart failure (HF) and the influence of left ventricular ejection fraction (LVEF) in the setting of acute coronary syndrome (ACS) are scant. The aim of this study was to examine the relationship between LVEF and HF with long-term prognosis in a cohort of patients with ACS.

METHODS

This is a retrospective observational study of 6208 patients consecutively admitted for ACS to 2 different Spanish hospitals. Baseline characteristics were examined and a follow-up period was established for registration of death and HF rehospitalization as the primary endpoint.

RESULTS

Among the study participants, 5064 had ACS without HF during hospitalization: 290 (5.8%) had LVEF<40%, 540 (10.6%) LVEF 40% to 49%, and 4234 (83.6%) LVEF ≥ 50%. The remaining 1144 patients developed HF in the acute phase: 395 (34.6%) had LVEF<40%, 251 (21.9%) LVEF 40% to 49%, and 498 (43.5%) LVEF ≥ 50%. Patients with LVEF 40% to 49% had a demographic and clinical profile with intermediate features between the LVEF <40% and LVEF ≥ 50% groups. Kaplan-Meier curves showed that mortality and HF readmissions were statistically different depending on LVEF in the non-HF group but not in the HF group. Left ventricular ejection fraction ≥ 50% was an independent prognostic factor in the non-HF group only.

CONCLUSIONS

In ACS, long-term prognosis is considerably worse in patients who develop HF during hospitalization than in patients without HF, irrespective of LVEF. This parameter is a strong prognostic predictor only in patients without HF.

Heart failure after myocardial infarction in the era of primary percutaneous coronary intervention: Mechanisms, incidence and identification of patients at risk

Myocardial infarction (MI) remains the most common cause of heart failure (HF) worldwide. For almost 50 years HF has been recognised as a determinant of adverse prognosis after MI, but efforts to promote myocardial repair have failed to translate into clinical therapies. Primary percutaneous coronary intervention (PPCI) has driven improved early survival after MI, but its impact on the incidence of downstream HF is debated. The effects of PPCI are confounded by the changing epidemiology of MI and HF, with an ageing patient demographic, an increasing proportion of non-ST-elevation myocardial infarction, and the recognition of HF with preserved ejection fraction. Herein we review the mechanisms of HF after MI and discuss contemporary data on its incidence and outcomes. We review current and emerging strategies for early detection of patients at risk of HF after MI, with a view to identification of patient cohorts for novel therapeutic agents.

The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG) Medicare-linked database

BACKGROUND

Little is known about the relationship between ejection fraction (EF) and clinical outcomes among older patients with myocardial infarction in contemporary clinical practice.

METHODS

Data on 82,558 patients 65 years or older with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction who survived to hospital discharge in the ACTION Registry-GWTG (2007-2011) were linked to Medicare data. Multivariable Cox proportional hazard modeling was used to assess the association between EF reported during hospitalization and 1-year mortality, using EF as a categorical variable (≤35%, >35% and ≤45%, >45% and <55%, and ≥55%) and as a continuous variable. Secondary outcomes of interest were 1-year all-cause, cardiovascular, and heart failure readmissions.

RESULTS

The risk of 1-year mortality was 29.0% in patients with EF ≤ 35%, compared with 13.0% in patients in the reference group, EF ≥ 55% (adjusted hazard ratio [HR] 1.58, 95% CI 1.51-1.66). Relative to patients with EF ≥ 55%, patients with EF ≤ 35% had an increased risk of 1-year all-cause readmission (adjusted HR 1.20, 95% CI 1.17-1.24), cardiovascular readmission (adjusted HR 1.36, 95% CI 1.31-1.41), and heart failure readmission (adjusted HR 2.43, 95% CI 2.28-2.60). For patients with EF ≤ 40%, the hazard of mortality increased by 26% for every 5% decrease in EF, a finding that remained after risk adjustment (adjusted HR 1.11, 95% CI 1.09-1.12).

CONCLUSIONS

Low EF after MI remains an important risk factor for postdischarge mortality and hospital readmission, even after adjustment for patient and hospital characteristics.

Predicting Outcomes Over Time in Patients With Heart Failure, Left Ventricular Systolic Dysfunction, or Both Following Acute Myocardial Infarction

Background

Most studies of risk assessment or stratification in patients with myocardial infarction (MI) have been static and fail to account for the evolving nature of clinical events and care processes. We sought to identify predictors of mortality, cardiovascular death or nonfatal MI, and cardiovascular death or nonfatal heart failure (HF) over time in patients with HF, left ventricular systolic dysfunction, or both post‐MI.

Methods and Results

Using data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial, we developed models to estimate the association between patient characteristics and the likelihood of experiencing an event from the time of a follow‐up visit until the next visit. The intervals are: hospital arrival to discharge or 14 days, whichever occurs first; hospital discharge to 30 days; 30 days to 6 months; and 6 months to 3 years. Models were also developed to predict the entire 3‐year follow‐up period using baseline information. Multivariable Cox proportional hazards modeling was used throughout with Wald chi‐squares as the comparator of strength for each predictor. For the baseline model of overall mortality, the 3 strongest predictors were age (adjusted hazard ratio [HR], 1.35; 95% CI, 1.28–1.42; P<0.0001), baseline heart rate (adjusted HR, 1.17; 95% CI, 1.14–1.21; P<0.0001), and creatinine clearance (≤100 mL/min; adjusted HR, 0.86; 95% CI, 0.84–0.89; P<0.0001). According to the integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices, the updated model had significant improvement over the model with baseline covariates only in all follow‐up periods and with all outcomes.

Conclusions

Patient information assessed closest to the time of the outcome was more valuable in predicting death when compared with information obtained at the time of the index hospitalization. Using updated patient information improves prognosis over using only the information available at the time of the index event.

The value of novel invasive hemodynamic parameters added to the TIMI risk score for short-term prognosis assessment in patients with ST segment elevation myocardial infarction

BACKGROUND

We compared the prognostic capacity of conventional and novel invasive parameters derived from the slope of the preload recruitable stroke work relationship (PRSW) in STEMI patients and assessed their contribution to the TIMI risk score.

METHODS

Left ventricular end-diastolic pressure (EDP), ejection fraction (EF), pressure adjusted maximum rate of pressure change in the left ventricle (dP/dt/P), aortic systolic pressure to EDP ratio (SBP/EDP) and end-diastolic volume adjusted stroke work (EW), derived from the slope of the PRSW relationship, were obtained during the emergency cardiac catheterization in 523 STEMI patients. The predictive power of the analyzed parameters for 30-day and 1-year mortality was evaluated using C-statistics and reclassification analysis was adopted to assess the improvement in TIMI score.

RESULTS

The highest area under the curve (AUC) values for 30-day mortality were observed for EW (0.872(95% confidence interval 0.801-0.943)), SBP/EDP (0.843(0.758-0.928)) and EF (0.833(0.735-0.931)); p<0.001 for all values. For 1-year mortality the best predictive value was found for EW (0.806(0.724-0.887) and EF (0.793(0.703-0.883)); p<0.001 for both. The addition of EDP, SBP/EDP ratio and EW to TIMI score significantly increased the AUC according to De Long's test. For 30-day mortality, increased discriminative power following addition to the TIMI score was observed for EW and SBP/EDP (Integrated Discrimination Improvement was 0.086(0.033-0.140), p=0.002 and 0.078(0.028-0.128), p=0.002, respectively).

CONCLUSIONS

EW and SBP/EDP are prognostic markers with high predictive value for 30-day and 1-year mortality. Both parameters, easily obtained during emergency catheterization, improve the discriminatory capacity of the TIMI score for 30-day mortality.

Heart failure with preserved left ventricular ejection fraction in patients with acute myocardial infarction

Background

The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated.

Objective

To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality.

Methods

Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models.

Results

Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality.

Conclusion

One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization.

The Prognostic Significance of Resting Regional Left Ventricular Function in Patients With Varying Degrees of Myocardial Ischemia

Background

Our aim was to determine whether regional left ventricular (LV) function on a resting transthoracic echo (TTE) provides prognostic information in patients with varying degrees of ischemia on myocardial perfusion imaging.

Methods

Between 2004 - 2009, we identified 503 patients (mean age 69 (SD 11); 79% male) with reversible ischemia on a myocardial SPECT scan who had a TTE within 30 days. We evaluated the rate of subsequent revascularization and death for all patients.

Results

Following the SPECT scan and TTE, 246/503(49%) patients underwent revascularization, 64/503 (13%) patients died, 369 (73%) patients had a normal left ventricular ejection fraction (LVEF), 242 (48%) patients had a resting wall motion abnormality (WMA), 21/261 (8%) with no WMA died compared to 43/242 (18%) in patients with a WMA. In patients with a WMA (n = 242) there was no significant difference in mortality when comparing patients with small (< 6 segments) and large (> 6 segments) WMA (P = 0.44). In patients with moderate/severe ischemia, the presence of a resting WMA was associated with a higher mortality rate (18% v 7%; P = 0.005). In a multivariable model, LVEF (< 50%) was associated with a hazard ratio of 2.2 (P = 0.002, 95% CI 1.34 - 3.68) however, WMA and number of abnormal segments did not reach statistical significance.

Conclusion

A resting wall motion abnormality in patients with moderate/severe ischemia is associated with a higher mortality compared to patients with mild ischemia on myocardial perfusion imaging. Regional left ventricular dysfunction unlike LVEF was not an independent predictor of mortality.

Elevated admission microalbuminuria predicts poor myocardial blood flow and 6-month mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

BACKGROUND

Microalbuminuria (MA) is considered a major risk factor predisposing to cardiovascular morbidity and mortality. Outcomes after percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI) complicated by MA have been well described. However, data regarding admission MA and coronary and myocardial flow are scant. The aims of this study were to evaluate the effects of admission MA on coronary blood flow and prognosis in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI.

HYPOTHESIS

Did elevated admission microalbuminuria predict poor myocardial blood flow and 6-month mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention?

METHODS

A total of 247 patients undergoing primary PCI for STEMI within 12 hours after symptom onset were studied. Patients were divided into 2 groups according to admission urinary albumin extraction rate (UAER): (1) an MA group (UAER 20-200 µg/min), and (2) a normoalbuminuria (NA) group (UAER < 20 µg/min).

RESULTS

Microalbuminuria was observed in 108 patients. Univariate analyses showed statistical differences between the NA and MA groups in serum creatine level, plasma glucose level, and peak creatine kinase level on presentation. Thrombolysis In Myocardial Infarction (TIMI) flow grades (TFGs) 0-2 in the MA group were more frequent (9.4% vs 21.2%, P < 0.05) than in the NA group, and corrected TIMI frame count was higher (23.9 ± 18.5 vs 29.8 ± 23.5, P < 0.05). Admission MA was an independent predictor of poor myocardial perfusion (adjusted relative risk: 3.14, 95% confidence interval: 0.99-6.78) and a higher rate of 6-month mortality in STEMI patients undergoing primary PCI (adjusted relative risk: 1.58, 95% confidence interval: 0.74-3.39).

CONCLUSIONS

Admission MA levels are associated with impaired myocardial flow and poor prognosis in STEMI patients undergoing primary PCI.

Heart failure and non-ST-segment elevation myocardial infarction: a review for a widespread situation

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

Omega-3 polyunsaturated fatty acids: a necessity for a comprehensive secondary prevention strategy

Long-chain omega-3 polyunsaturated fatty acid (PUFA) supplementation has been used for the secondary prevention of fatal and nonfatal myocardial infarction (MI). However, the benefit of this therapy is frequently confused with other established treatments in the therapeutic strategy among such patients. We review the data on omega-3 PUFA use in secondary care and consider indications for its use which include post-MI and raised triglycerides. We suggest that the available evidence supports the use of omega-3 supplementation as part of the comprehensive secondary care package for post-MI patients.

Predictors of preoperative depressive risk in patients undergoing coronary artery bypass graft surgery

AIMS

Depression is highly prevalent among patients undergoing coronary artery bypass graft (CABG) surgery and represents a significant risk factor for longer hospitalization, increasing health costs and worse outcomes. Nonetheless, preoperative depression is rarely assessed in clinical practice, limiting the possibilities for effective prevention and care. Thus, we sought to develop risk models to determine the depressive risk before CABG based on sociodemographic, clinical and treatment variables.

METHODS AND RESULTS

One thousand two hundred and thirty-eight CABG-patients completed the 9-item Patient Health Questionnaire (PHQ-9) prior to surgery. Clinical and sociodemographic data were collected by trained study investigators. Overall 21.6% of patients displayed elevated depression scores, which were twice as common in women than in men (34.7 versus 17.9%, P < 0.001). Following bivariate analysis, multiple regression revealed that both dyspnea at rest (OR 1.69, 95% CI 1.11-2.57, P = 0.015) and dyspnea on exertion (OR 2.48, 95% CI 1.61-3.81, P < 0.001), previous myocardial infarction (OR 1.53, 95% CI 1.12-2.08, P = 0.007), comorbidities and medication with tranquillizers; in addition to younger age, female gender, lower school education, and living alone are significantly and independently associated with preoperative depressive symptoms.

CONCLUSIONS

Knowledge of these risk factors will allow for better identification of patients at high depressive risk and thereby facilitate optimal treatment in order to improve postoperative outcomes.

Circulating biomarkers of angiogenesis as indicators of left ventricular systolic dysfunction amongst patients with coronary artery disease

BACKGROUND

Patients with coronary artery disease (CAD) and left ventricular systolic dysfunction (LVSD) are often asymptomatic. Angiogenesis is implicated in the physiology of vascular repair and cardiac remodelling, and is one of many pathophysiological processes implicated in heart failure. We hypothesized that plasma indices associated with angiogenesis [angiogenin, vascular endothelial growth factor (VEGF), and angiopoietin (Ang)-1 and Ang-2] would be abnormal in CAD patients with LVSD, being correlated with EF and wall motion abnormalities (wall motion score) independently of underlying CAD (coronary atheroma score). We also evaluated the specificity of angiogenic 'biomarkers' in their detection of LVSD [ejection fraction (EF) <40%] amongst CAD patients.

METHODS

Using a cross sectional approach, we measured angiogenin, VEGF, Ang-1 and Ang-2 by ELISA in 194 CAD patients (aged 34-81 years) undergoing elective coronary angiography.

RESULTS

Levels of angiogenin were inversely related with EF (r = -0.17, P = 0.02) and positively with coronary atheroma scores (r = 0.15, P = 0.04, but not independently of EF). Other angiogenic markers were unrelated to objective measures of LVSD but VEGF (P = 0.008) and Ang-2 (P = 0.015) were lower amongst those patients with heart failure. Angiogenin levels were related to wall motion scores (r = 0.16, P = 0.024).

CONCLUSION

Heart failure has a modest impact on biomarkers of angiogenesis, in patients with CAD. Further research is warranted into the diagnostic and prognostic utility of biomarkers of angiogenesis, in this common cardiac condition.

Predicting clinically unrecognized coronary artery disease: use of two- dimensional echocardiography

BACKGROUND

2-D Echo is often performed in patients without history of coronary artery disease (CAD). We sought to determine echo features predictive of CAD.

METHODS

2-D Echo of 328 patients without known CAD performed within one year prior to stress myocardial SPECT and angiography were reviewed. Echo features examined were left ventricular and atrial enlargement, LV hypertrophy, wall motion abnormality (WMA), LV ejection fraction (EF) < 50%, mitral annular calcification (MAC) and aortic sclerosis/stenosis (AS). High risk myocardial perfusion abnormality (MPA) was defined as >15% LV perfusion defect or multivessel distribution. Severe coronary artery stenosis (CAS) was defined as left main, 3 VD or 2VD involving proximal LAD.

RESULTS

The mean age was 62 +/- 13 years, 59% men, 29% diabetic (DM) and 148 (45%) had > 2 risk factors. Pharmacologic stress was performed in 109 patients (33%). MPA was present in 200 pts (60%) of which, 137 were high risk. CAS was present in 166 pts (51%), 75 were severe. Of 87 patients with WMA, 83% had MPA and 78% had CAS. Multivariate analysis identified age >65, male, inability to exercise, DM, WMA, MAC and AS as independent predictors of MPA and CAS. Independent predictors of high risk MPA and severe CAS were age, DM, inability to exercise and WMA. 2-D echo findings offered incremental value over clinical information in predicting CAD by angiography. (Chi square: 360 vs. 320 p = 0.02).

CONCLUSION

2-D Echo was valuable in predicting presence of physiological and anatomical CAD in addition to clinical information.

Cardiac resynchronization therapy evaluated by myocardial scintigraphy with 99mTc-MIBI: changes in left ventricular uptake, dyssynchrony, and function

PURPOSE

(99m)Tc-MIBI gated myocardial scintigraphy (GMS) evaluates myocyte integrity and perfusion, left ventricular (LV) dyssynchrony and function. Cardiac resynchronization therapy (CRT) may improve the clinical symptoms of heart failure (HF), but its benefits for LV function are less pronounced. We assessed whether changes in myocardial (99m)Tc-MIBI uptake after CRT are related to improvement in clinical symptoms, LV synchrony and performance, and whether GMS adds information for patient selection for CRT.

METHODS

A group of 30 patients with severe HF were prospectively studied before and 3 months after CRT. Variables analysed were HF functional class, QRS duration, LV ejection fraction (LVEF) by echocardiography, myocardial (99m)Tc-MIBI uptake, LV end-diastolic volume (EDV) and end-systolic volume (ESV), phase analysis LV dyssynchrony indices, and regional motion by GMS. After CRT, patients were divided into two groups according to improvement in LVEF: group 1 (12 patients) with increase in LVEF of 5 or more points, and group 2 (18 patients) without a significant increase.

RESULTS

After CRT, both groups showed a significant improvement in HF functional class, reduced QRS width and increased septal wall (99m)Tc-MIBI uptake. Only group 1 showed favourable changes in EDV, ESV, LV dyssynchrony indices, and regional motion. Before CRT, EDV, and ESV were lower in group 1 than in group 2. Anterior and inferior wall (99m)Tc-MIBI uptakes were higher in group 1 than in group 2 (p<0.05). EDV was the only independent predictor of an increase in LVEF (p=0.01). The optimal EDV cut-off point was 315 ml (sensitivity 89%, specificity 94%).

CONCLUSION

The evaluation of EDV by GMS added information on patient selection for CRT. After CRT, LVEF increase occurred in hearts less dilated and with more normal (99m)Tc-MIBI uptake.

Predictive power of systolic function and congestive heart failure in patients with patients admitted for chest pain without ST elevation in the troponin era

BACKGROUND

Impaired systolic function and congestive heart failure (CHF) are powerful predictors of adverse outcomes in patients with myocardial infarction (MI). However, there are little data in which both of these variables were assessed in heterogenous patients admitted from the emergency department for exclusion of ischemia.

METHODS

Consecutive patients admitted for MI exclusion who had ejection fraction (EF) measured were included. Systolic dysfunction was defined as EF <40%. Congestive heart failure was diagnosed based on clinical or x-ray evidence in the first 24 hours. Multivariate analysis was used to determine predictors of 30-day and 1-year mortality.

RESULTS

Of the 4,343 consecutive patients admitted, 3,682 (85%) had EF assessed (including 97% of the troponin I [TnI]-positive patients) and were included. One-year unadjusted mortality was 9.5%, but in the presence of systolic dysfunction or CHF, it increased to 22% and 26%, respectively. The most important multivariate predictors of 30-day and 1-year mortality were similar and included CHF (OR for 1-year mortality 2.5, 95% CI 1.9-3.4), TnI elevations (OR 2.0, 95% CI 1.5-2.6), and severe renal failure (OR 5.2, 95% CI 3.7-7.2). Systolic dysfunction was predictive of 1 year (OR 1.9, 95% CI 1.4-2.5) but not 30-day mortality. Results were similar in the 3,018 patients who were troponin-negative.

CONCLUSIONS

Congestive heart failure is an independent predictor of both short- and long-term mortality in patients admitted for MI exclusion. In contrast, systolic dysfunction predicts long-term but not short-term mortality. One cannot be used as a surrogate for the other.

Effect of depression on late (8 years) mortality after myocardial infarction

Depression during hospitalization for myocardial infarction (MI) is associated with subsequent mortality, but whether this risk persisted long term is not well studied. This study was performed to determine whether depression during hospitalization for MI, which predicted mortality at 4 months, predicted mortality 8 years later. This was a prospective observational study of 284 hospitalized patients with MI. Major depression and dysthymia were assessed using structured interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and depressive symptoms, using the Beck Depression Inventory. Mortality was determined using the Social Security Death Index. Mean age during MI hospitalization was 64.8 years, 43.0% of patients were women, 66.7% had hypertension, and 35.7% had diabetes mellitus. Any depression (major depression, dysthymia, and/or Beck Depression Inventory score > or =10) was present in 76 patients (26.8%). The 8-year mortality rate was 47.9% (136 deaths). Any depression at the time of MI was not associated with mortality at 8 years in unadjusted (hazard ratio 1.25, 95% confidence interval 0.87 to 1.81, p = 0.22) or multivariate models (hazard ratio 0.76, 95% confidence interval 0.47 to 1.24, p = 0.27). In conclusion, depression after MI was associated with increased short-term mortality, but its relation with mortality over time appeared to wane, at least in a group of older patients who had multiple co-morbidities.

Restrictive Filling Pattern is a Powerful Predictor of Heart Failure Events Postacute Myocardial Infarction and in Established Heart Failure: A Literature-Based Meta-Analysis

BACKGROUND

Two recent literature-based meta-analyses revealed that restrictive filling pattern (RFP) was associated with a 4-fold increase in the risk of death in patients with heart failure (HF) and postacute myocardial infarction (AMI). This similar but unique analysis evaluated the link between RFP and morbidity.

METHODS AND RESULTS

Prospective echocardiographic studies of patients post-AMI and with HF that reported HF morbidity were identified. Events (post-AMI: development of HF; HF: HF readmission) were compared between patients with and without RFP in both patient groups. Review Manager version 4.2.7 software was used for the analysis. Twelve post-AMI studies (1286 patients, 271 events) and 5 HF studies (647 patients, 176 events) were identified. RFP was associated with HF readmission in the HF patients (OR 2.96 [2.02-4.33] and development of HF post-AMI (OR 10.10 [7.02-14.51]). The event rate in the RFP group was the same regardless of disease category (49% post-AMI, 42% HF); however, RFP was less prevalent in the post-AMI group (22% versus 39%).

CONCLUSIONS

This literature-based meta-analysis confirms that RFP is a powerful predictor of HF hospitalization in patients with HF and especially the development of HF post-AMI. This is an important prognostic sign and should be incorporated into routine clinical practice.

Epidemiology of heart failure and left ventricular dysfunction after acute myocardial infarction

The development of heart failure and/or left ventricular systolic dysfunction has long been regarded as an ominous complication, significantly increasing the morbidity and short- and long-term mortality of survivors of acute myocardial infarction. Although the incidence of heart failure after myocardial infarction has fallen over the last few decades, it remains common, complicating up to 45% of infarcts. Moreover, up to 60% of myocardial infarcts will result in left ventricular systolic dysfunction, depending on the exact definition used. Those at greatest risk of developing heart failure are the elderly, females, and those with prior myocardial infarction. Advances in the management of acute myocardial infarction have led to reduced in-hospital mortality (even when complicated by heart failure), but longer-term mortality remains high in these patients.

Comparison of Regional Versus Global Assessment of Left Ventricular Function in Patients with Left Ventricular Dysfunction, Heart Failure, or Both After Myocardial Infarction: The Valsartan in Acute Myocardial Infarction Echocardiographic Study

BACKGROUND

Left ventricular (LV) ejection fraction (EF) and wall-motion index (WMI) have both been shown to be independent predictors of outcome after myocardial infarction (MI).

OBJECTIVES

We sought to determine whether these two measurements of LV systolic function provide similar or complementary information about prognosis after MI.

METHODS

Echocardiography was performed in 610 patients with LV dysfunction, heart failure, or both after MI enrolled in the Valsartan in Acute MI trial. LVEF was estimated by biplane Simpson's rule, and WMI was assessed using a 16-segment model in 502 patients with echocardiograms of sufficient quality for wall-motion assessment.

RESULTS

Both LVEF and WMI were independent predictors of adverse outcome after MI. LVEF conferred no additional prognostic information in multivariable analysis including WMI (P = .39) or number of affected segments (P = .53), whereas WMI (P = .02) and total number of affected segments (P = .006) remained significant even when adjusting for LVEF.

CONCLUSIONS

Assessment of regional dysfunction by WMI or the number of affected segments has slightly more prognostic value than LVEF in patients with LV dysfunction, heart failure, or both after MI. Regional assessment might be a more sensitive predictor of outcome than global assessment in patients with acute MI.

Rationale and design of a randomized, double-blind, placebo-controlled trial of ivabradine in patients with stable coronary artery disease and left ventricular systolic dysfunction: the morBidity-mortality EvAlUaTion of the I(f) inhibitor ivabradine in patients with coronary disease and left ventricULar dysfunction (BEAUTIFUL) study

BACKGROUND

Raised resting heart rate (HR) is associated with increased cardiovascular and total mortality. Ivabradine is a new specific HR-reducing agent, which has been shown to have antianginal and anti-ischemic properties in patients with stable angina. Because patients with coronary artery disease and left ventricular dysfunction are at high risk of cardiac events and death, we hypothesized that they could derive particular benefit from a specific HR-lowering agent such as ivabradine.

METHODS

BEAUTIFUL is a multicenter, randomized, international, double-blind placebo-controlled trial to evaluate the superiority of ivabradine over placebo in reducing cardiovascular events in patients with stable coronary artery disease and left ventricular systolic dysfunction (ejection fraction < or = 39%). The primary end point is the composite of cardiovascular mortality and hospital admission for acute myocardial infarction or new onset or worsening of heart failure. This event-driven study will randomize 9650 patients and continue until 950 primary end points have occurred, providing 90% power to detect a 19% reduction in relative risk. In approximately 660 centers, men and women aged > or = 55 years if nondiabetic and > or = 18 years if diabetic are randomized to placebo or oral ivabradine (5 mg twice daily for 2 weeks then target dose of 7.5 mg twice daily). Follow-up is expected to last between 18 and 36 months.

RESULTS

The first patient was randomized in January 2005.

CONCLUSION

BEAUTIFUL will be the first major outcome trial of a specific HR-reducing agent. The study results are expected in 2008.

Extent of coronary artery disease as a predictor of outcomes in acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both

BACKGROUND

Left ventricular systolic dysfunction (LVSD) and heart failure (HF) are powerful predictors of poor outcome after acute myocardial infarction (MI). It is not known, however, whether the extent of coronary artery disease (CAD) independently influences cardiovascular (CV) outcomes in these high-risk patients.

METHODS

In the VALIANT, 14703 patients were randomly assigned to receive either captopril monotherapy, valsartan monotherapy, or a valsartan and captopril combination between 0.5 and 10 days after acute MI complicated by LVSD, HF, or both. Cox proportional hazards models were used to evaluate the relation between the extent of CAD (the number of diseased vessels as assessed by angiography) and a range of CV outcomes and all-cause mortality.

RESULTS

Coronary angiography data were available on 5742 (40%) of the 14703 randomized patients. Single-vessel disease was reported in 1955 patients (34%), 2-vessel disease in 1598 (28%), and 3-vessel disease in 2189 (38%). For all CV outcomes, the risk increased with the severity of CAD (P for trend < .002). A comparison of single-, 2-, and 3-vessel disease showed that, after adjusting for all known covariates, including revascularization and ejection fraction, 2-vessel disease was associated with a 40% increased hazard (P = .008) and 3-vessel disease was associated with an 85% increased hazard (P < .001) for all-cause mortality. The fully adjusted hazard ratios for death and other CV outcomes increased significantly with increasing extent of CAD.

CONCLUSIONS

Increasing extent of CAD, as detected by angiography, is a significant and independent risk factor for adverse CV outcomes after MI complicated by HF, LVSD, or both. The observed risk was apparent even after excluding patients who had undergone revascularization.

Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance

The development of heart failure and/or left ventricular systolic dysfunction (LVSD) in the setting of acute myocardial infarction (AMI) results in significant risk far above that of AMI independently. In patients admitted to the hospital for AMI, concomitant heart failure and/or LVSD on hospital admission or development of either or both of these conditions during admission are among the strongest predictors of inhospital death and are associated with significant increases in inhospital, 30-day, and long-term mortality and rehospitalization rates. Given the high risks in this population, aggressive treatment, comprising early initiation and sustained use of evidence-based treatments, is essential for improving prognosis.

Sudden cardiovascular death following myocardial infarction: the importance of left ventricular systolic dysfunction and congestive heart failure

BACKGROUND

To study the prognostic information of congestive heart failure (CHF) and left ventricular systolic dysfunction regarding sudden and non-sudden cardiovascular death (SCD and non-SCD) in patients with acute myocardial infarction (MI), as this may indicate the potential benefit of implantable defibrillators.

METHODS

Data from consecutive patients with acute MI screened in 1990-92 for the TRAndolapril Cardiac Evaluation (TRACE) study were entered into a registry. A total of 5502 patients were alive 30 days after the MI and were followed for up to 4 years with respect to cause of death. SCD was defined as cardiovascular death within 1 h of onset of symptoms. An echocardiography was performed 1-6 days after the admission and evaluated centrally using the wall motion index (WMI).

RESULTS

Half of the patients had CHF and 17% of the patients had WMI < or =1.0 (corresponding to an ejection fraction < or =0.30). During follow-up 431 patients died from SCD and 606 from non-SCD. The risk ratios for SCD and non-SCD associated with WMI < or =1.0 were 3.17 and 2.95, transient CHF 2.01 and 1.46, and permanent CHF 3.71 and 4.42, respectively. No risk factor was a specific marker of SCD or non-SCD. The 3-year probability of SCD was 7.9% for patients with transient CHF, 13.3% for permanent CHF, and 15.5% for WMI < or =1.0.

CONCLUSIONS

CHF and low WMI identify a relevant proportion of patients with MI who are at high absolute risk of SCD. This study indicates the relevance of defibrillators in consecutive post-MI patients with left ventricular dysfunction or clinical signs of heart failure.

Long-term outcome after primary stenting versus balloon angioplasty for acute myocardial infarction

The objective of the present prospective multicenter case-control study was to investigate the long-term clinical outcome (5 years) of primary stenting compared to primary percutaneous transluminal coronary angioplasty (PTCA) without stenting (POBA) in patients with acute myocardial infarction at 7 cardiovascular centers in Hokkaido, Japan. Forty-one patients with acute myocardial infarction treated with successful primary stenting (stent group: case) and paired with 41 matched control subjects with acute myocardial infarction treated by successful primary PTCA without stenting (POBA group: control) were analyzed. After 1 year, the stent group had a lower incidence of the combined clinical endpoint (death, rehospitalization due to congestive heart failure, nonfatal myocardial infarction, repeat angioplasty, CABG, or cerebrovascular events) compared to the POBA group (17.1% versus 39.0%, P = 0.049). After 5 years, the incidences of congestive heart failure and cardiac death were the same in both groups. However, compared to the POBA group, the stent group had a lower combined clinical endpoint (34.1% versus 61.0%, P = 0.027). The Kaplan-Meier event-free survival curves of the stent group showed a significantly lower occurrence of clinical events compared to the POBA group (P = 0.0116). Multiple logistic regression analysis of clinical events identified age > or = 69 years (P = 0.0092, odds ratio = 4.179) and stenting (P = 0.0158, odds ratio = 0.279) as explanatory factors. Compared with POBA, primary stenting for acute myocardial infarction results in a better long-term clinical outcome.

A Novel Data Mining Approach to the Identification of Effective Drugs or Combinations for Targeted Endpoints?Application to Chronic Heart Failure as a New Form of Evidence-based Medicine

BACKGROUND

Data mining is a technique for discovering useful information hidden in a database, which has recently been used by the chemical, financial, pharmaceutical, and insurance industries. It may enable us to detect the interesting and hidden data on useful drugs especially in the field of cardiovascular disease.

METHODS AND RESULTS

We evaluated the current treatments for chronic heart failure (CHF) in our institute using a decision tree method of data mining and compared the results with those of large-scale clinical trials. We enrolled 1,100 patients with CHF (NYHA classes II-IV and EF < 40%) who were hospitalized at the National Cardiovascular Center during the past 31 months. Drugs prescribed at discharge were extracted from the clinical database. Both echocardiograms and plasma BNP level at 6-12 months after discharge were determined prospectively. It was found that beta-blockers, angiotensin converting enzyme inhibitors, and angiotensin II receptor antagonists independently improve both the plasma BNP level and %fractional shortening (FS), while oral inotropic agents increased the plasma BNP level and decreased %FS. These findings agree with evidence accumulated from several large-scale trials. Interestingly, statins, histamine receptor blockers, and alpha-glucosidase inhibitors also attenuated the severity of CHF, suggesting the possibility of new treatment of CHF.

CONCLUSION

Clinical data mining using Japanese CHF patients yielded almost identical data to the results of large-scale trials, and also suggested novel and unexpected candidates for CHF therapy. Further validation of the data mining approved in the cardiovascular field is warranted.

Predictors of late development of heart failure in stable survivors of myocardial infarction: the CARE study

OBJECTIVES

We sought to determine the predictors of heart failure (HF) development in long-term survivors of myocardial infarction (MI).

BACKGROUND

Modern strategies of acute MI care have resulted in an increasing proportion of survivors at heightened risk of future non-fatal events, including HF.

METHODS

We assessed the risk of developing HF in 3860 stable MI patients without a previous history of HF, who were enrolled in the Cholesterol And Recurrent Events (CARE) trial a median of 10 months post MI. Baseline characteristics of patients who did or did not develop HF during the five years of observation were assessed.

RESULTS

A total of 243 patients (6.3%) developed HF in a linear pattern at a rate of 1.3%/year. Heart failure development markedly increased the risk of death (hazard ratio 10.2, 95% confidence interval 7.7 to 13.5). Fifty-seven patients (23.5%) who developed HF had a recurrent MI between enrollment and the onset of HF, increasing the risk fivefold. The most important predictors of HF were age and left ventricular ejection fraction. Other predictors included diabetes, history of hypertension, previous MI, and baseline heart rate. Moderate exercise three or more times per week was independently associated with a 30% lower risk of HF.

CONCLUSIONS

Heart failure post MI occurs in a time-dependent fashion, which is usually not a direct consequence of a detectable interim MI. Patients who experience late-onset HF have a 10-fold increased risk of death compared with other MI survivors. Baseline characteristics can risk stratify patients at high risk of subsequent HF.

C-reactive protein in acute myocardial infarction: association with heart failure

BACKGROUND

High C-reactive protein (CRP) levels have been associated with higher mortality rate in patients with acute myocardial infarction (AMI). However, it is not known whether inflammation plays a role in the time-course of heart failure (HF) in this clinical setting. Our aim was to study the nature of the relationship between CRP and HF during AMI.

METHODS

This prospective study was carried out in 269 subjects admitted to the hospital for suspected AMI. Of these, 220 had evidence of AMI. The other 49 subjects were studied as controls. CRP was assessed on the first, third, and seventh day after admission.

RESULTS

CRP was significantly higher in the patients with AMI than in the control patients (P =.001) and peaked on the third day. Among the patients with AMI, CRP was higher in patients with HF than in patients without HF (adjusted P =.008, P =.02 and P =.03 on 1st, 3rd, and 7th day, respectively). Prevalence of HF on admission was slightly higher in the subjects with first-day CRP >or=15 mg/L than in those with CRP <15 mg/L, and the between-group difference progressively increased from the first to the seventh day (P <.0001). At multivariable regression analysis, first-day log-CRP was shown to be a strong independent predictor of both HF progression (P <.0001) and left ventricular ejection fraction (P <.0001). One-year total mortality and HF-mortality rates turned out to be higher in the patients with CRP >or=85 mg/L than in those with CRP below that level (P <.0001), and log-third-day CRP was independently associated with 1-year mortality at multivariable analysis (P =.0001).

CONCLUSIONS

CRP on admission to hospital is suitable for predicting the time-course of HF in patients with AMI. Peak CRP value is a strong independent predictor of global and HF-mortality during the following year.

Increased myocardial apoptosis in patients with unfavorable left ventricular remodeling and early symptomatic post-infarction heart failure

OBJECTIVES

The purpose of this study was to evaluate a potential correlation between apoptotic rate (AR), post-infarction left ventricular (LV) remodeling, and clinical characteristics in subjects who died late (>or=10 days) after an acute myocardial infarction (AMI) with evidence of persistent occlusion of the infarct-related artery at autopsy.

BACKGROUND

Apoptosis contributes to myocardiocyte loss in cardiac disease and may have a pathophysiologic role in post-infarction LV remodeling.

METHODS

The AR was calculated at the site of infarction and in remote unaffected LV regions, using co-localization of in situ end labeling for deoxyribonucleic acid fragmentation and immunohistochemistry for caspase-3, in 14 subjects who died within two months after AMI. Correlation between AR and clinical characteristics such as age, site of AMI, transmural extension, multivessel coronary disease, and signs and/or symptoms of heart failure (HF), at the time of initial hospitalization for AMI or subsequently before death, was assessed using non-parametric statistical tests. Parameters of LV remodeling including diameters, free wall thickness, diameter-to-wall-thickness ratio, and mass were measured at gross examination at autopsy. Values are expressed as median (interquartile range).

RESULTS

Among clinical variables, early symptomatic post-infarction HF (9 cases, 64%) was associated with nearly fourfold increased AR at the site of infarction (26.2% [24.5% to 28.8%] vs. 6.4% [1.9% to 13.3%], p = 0.001). Moreover, AR both at the site of infarction and in unaffected regions was significantly correlated with parameters of progressive LV remodeling (p < 0.05).

CONCLUSIONS

Our data show that in patients dying >or=10 days after AMI, myocardial apoptosis is strongly associated with and may be a major determinant of unfavorable LV remodeling and early symptomatic post-infarction HF.

The relevance of subgroup-specific treatment effects: the Studies Of Left Ventricular Dysfunction (SOLVD) revisited

BACKGROUND

The overall effect sizes estimated from randomized clinical trials may not apply similarly to all patients. Univariate subgroup analyses are often used to help determine the generalizability of a trial's results, but may themselves be misleading. We reanalyzed the Studies of Left Ventricular Dysfunction (SOLVD) to determine whether the treatment effect depended on the patients' baseline prognosis, defined on the basis of multiple clinical variables.

METHODS

The SOLVD prevention (4228 patients) and the SOLVD treatment (2569 patients) trials were randomized, double-blind trials that studied the effect of enalapril in patients with reduced left-ventricular function or congestive heart failure. We combined both SOLVD populations and compared the results of a univariate analysis to a multivariate approach in which 3 patient subgroups were defined according to baseline risks for the combined end point of death or hospitalization for heart failure.

RESULTS

Enalapril treatment resulted in 24% fewer events. The strongest predictors of an event were ejection fraction, New York Heart Association classification and age, antiplatelet agents, history of diabetes mellitus, treatment with digoxin or diuretics, and race. Only ejection fraction produced a significant treatment interaction (P =.004). Consistent with the original SOLVD reports, this interaction was also demonstrable when ejection fraction was scaled into tertiles and examined on its own (P =.012). However, there was no interaction present when patients were divided into tertiles of multifactorial baseline risk.

CONCLUSIONS

We confirmed the treatment effect of enalapril, the impact of left-ventricular systolic function, and the negative prognostic importance of diabetes mellitus in this population. Although ejection fraction led to a subgroup-treatment interaction in the main SOLVD publications, a multifactorial approach to prognostic grouping abolished the interaction. These findings highlight the limitations of univariate subgroup analyses and illustrate that multivariate risk group analysis may be a complementary method for assessing the generalizability of the overall treatment effects observed in randomized trials.

Heart failure after myocardial infarction: a review

PURPOSE

The effects of survival after myocardial infarction on the prevalence of chronic heart failure have not been well characterized. We reviewed studies of the incidence, mortality, and predictors of heart failure after myocardial infarction, and suggest directions for further research.

METHODS AND RESULTS

We conducted a review of the literature from 1978 to 2000. Of 33 identified articles, 18 (55%) included heart failure as a primary endpoint. The mean in-hospital incidence of heart failure after myocardial infarction differed significantly by study design; it was highest in population-based studies and lowest in clinical trials (37% vs. 18%, P <0.01). Only 10 studies reported the incidence of subsequent heart failure. One-year mortality ranged from 16% to 39% and showed no improvement with time. Patients with in-hospital heart failure after myocardial infarction had a two- to sixfold greater in-hospital mortality and up to a fivefold increased 1-year mortality compared with patients without heart failure. The most consistent risk factors for the development of heart failure after myocardial infarction were advanced age, female sex, diabetes, and an increased heart rate at the time of admission.

CONCLUSIONS

The reported incidence of, and mortality from, heart failure after myocardial infarction varies by study design. Additional research on the etiology and prognosis of late heart failure after myocardial infarction is needed.

Heterogeneity in the management and outcomes of patients with acute myocardial infarction complicated by heart failure: the National Registry of Myocardial Infarction

BACKGROUND

Heart failure (HF) is an important predictor of poor outcome after acute myocardial infarction (AMI). However, limited data exist about the clinical significance of HF in the coronary reperfusion era and the impact of its timing on hospital outcomes. The objective of this study was to determine the clinical impact of HF complicating AMI in the National Registry of Myocardial Infarction (NRMI). A secondary objective was to determine differences in demographic and clinical characteristics, treatment, and hospital death rates in patients presenting with HF compared with those developing HF after presentation.

METHODS AND RESULTS

The study sample consisted of patients with AMI and without a history of HF included in the NRMI. Of 606 500 cases included from July 1, 1994 to June 30, 2000, 123 938 (20.4%) patients had HF at the time of hospital presentation and 52 220 (8.6%) developed HF thereafter. Patients with HF were older, more likely female, had more comorbidities, and were less likely to receive effective cardiac medications compared with patients without HF. The multivariable adjusted odds for in-hospital death were higher for patients with HF at presentation and thereafter (3.1 and 5.5, respectively) than those without HF.

CONCLUSIONS

Results from this nationwide registry suggest that the incidence and hospital death rates associated with HF complicating AMI remain high. Patients developing HF after hospital admission are at even greater risk than those presenting with HF. Effective cardiac therapies remain underutilized in these patients, and the reasons for this underutilization need to be explored.